David Seastrom RN, BSN Trauma Outreach

& Education Coordinator Children’s Mercy Hospital

Child Abuse & Neglect

**Disclaimer**

The following presentation includes graphic depictions of , and !! nudity blood idiotic acts

Epidemiology – Abuse & Neglect

77 cases reported every hour 679,000 victims ever year >4 children die every day (1520/yr) Incarcerated Individuals were abused 14% men 36% women

Abused 9X more likely to be involved in criminal activity

We See This All To Often

Different Forms of Abuse

History

Mary Ellen Wilson (1874) Severely abuse at 9y/o

Heavy labor Beat constantly Locked in closets Slept on floor No winter clothes Forbidden to go out-doors

Used “cruelty to animals” laws to remove child from home

New York Society for the Prevention of Cruelty to Children

The Real Story

My father and mother are both dead. I don’t know how old I am. I have no recollection of a time when I did not live with the Connollys. Mamma has been in the habit of whipping and beating me almost every day. She used to whip me with a twisted whip—a rawhide. The whip always left a black and blue mark on my body. I have now the black and blue marks on my head which were made by mamma, and also a cut on the left side of my forehead which was made by a pair of scissors. She struck me with the scissors and cut me; I have no recollection of ever having been kissed by any one—have never been kissed by mamma. I have never been taken on my mamma's lap and caressed or petted. I never dared to speak to anybody, because if I did I would get whipped. I do not know for what I was whipped—mamma never said anything to me when she whipped me. I do not want to go back to live with mamma, because she beats me so. I have no recollection ever being on the street in my life.

How One Girl's Plight Started the Child-Protection Movement". American Humane Association. Retrieved 2009-05-18.

Still Child Abuse….

Child Abuse

High index of suspicion RF: poverty, single parent, substance

abuse, <2 yr, disability, low birth wt Cutaneuos injuries most common Death 2° head & abd trauma Interview child & parent separately

Child Abuse: Clues

History Story ≠ injuries History changing Injury ≠

development Delay seeking

help Inappropriate

level of concern

Physical Exam Multiple old and

new bruises (staging)

Posterior rib fx, sternum fx, spiral fx < 3

Immersion burns, cigarette (10-20%)

4 yo child reportedly fell down stairs of a deck Later that day, head swelling/bruising

noted Child brought to medical care by

mother Skull x-ray negative, child sent home Reported to CPS

“The Deck Did It”

CPS worker went to home Interviewed mother

Decided the fall down the stairs was the cause of the child’s findings Closed case

“The Deck Did It”

Child brought back to medical care 2 days later due to sleepiness ER doctors concerned

regarding possible abuse

“The Deck Did It”

ER documents bruising on forehead Neck petechiae Bruised chest Re-reported to CPS CPS states they already

investigated and closed the case

“The Deck Did It”

Child Abuse Physician consultant finds more bruising not noted in

the ER

“The Deck Did It”

CPS refuses to present the case to the Juvenile Officer Claims they already investigated

and closed Medical team takes custody

(legal in MO) Independently contacts the JO

Case Progression

After 5 days, the JO petitions the court and the court takes custody While being transported to foster care

the child discloses: She was hit by mom’s boyfriend on head,

choked, and spanked She doesn’t want to go home again Is afraid of her mother

Case Progression

• Case series of vertical gluteal cleft bruising

• Pattern not caused by object, but by the anatomy of the impacted tissue

•Caused by violent spanking, with the “sides” of the cleft pressing against each other as the child is hit

Data

Bruising on the neck, ears, in clusters is highly concerning for abuse Maguire 2005

Nearly 12% of household contacts of abused children < 5 years old have fractures on skeletal survey Lindberg 2012

25% of CPS workers think that physicians should not make recommendations regarding medical evaluations of contact children Berger 2010

Data

Communication and follow-up are key! Hospital systems need to be

designed to provide a “safety net” to catch misdiagnosed children

Take Home Points

Children benefit when MDT members stay within their roles Siblings/contacts of abused children

deserve a medical-forensic evaluation A “risk assessment” is not a method

to determine if a child’s injuries are abusive in nature

Take Home Points

1. Medical providers need to examine the child’s entire body

2. “Nice” people lie

3. Understand and define your respective roles

4. Respect professional boundaries

• Goes both ways

5. We should be on the same team

Take Home Points

WARNING: GRAPHIC CONTENT

Femur fracture (spiral or otherwise) often occur accidentally in young mobile children Immature bone in femurs in young

children is susceptible to fracture Especially with “torque” or twisting

Blakemore 1996, Pierce 2005

Data

80% of femur fx in children younger than walking age and 30% of femur fx in children <4 yo found to be abusive

Spiral fractures in children less than 6 yo no more likely to be abusive, but more likely to be investigated for abuse

Specifically in falls, transverse 33%, spiral 37%, oblique 14%

Confirmed child abuse: transverse 36%, spiral 36%, oblique 7%

Gross 1983, Scherl 2000

Femur Fractures

Non-ambulatory children: 42% of femur fractures due to abuse Ambulatory children: 2.6% of femur

fractures due to abuse Conclusion: developmental status

and history of event most important

Schwend 2000

Femur Fractures

Subjects were first evaluated by a “non-CAP” physician, then by a “CAP” physician Diagnoses regarding physical abuse

compared

Changes in 40% of cases. 80% of changes from abuse to non-abuse

Most valuable information from scene investigation by CPS

Data

Cases from rural areas 3x as likely to have a changed diagnosis

Conclusions: 1) CPS often isn’t provided with a medical diagnosis

regarding abuse 2) Consultations with child abuse experts often

results in a change in diagnosis 3) Child abuse experts often change a diagnosis

from abuse to non-abuse

Bruising Abuse

Bruising

Siblings often hold the key to diagnoses and identifying perpetrators All children with findings

concerning for abuse should be seen by a medical provider with pediatric forensic expertise

Take Home Points

EMOTIONAL BREAK

Non-accidental Burn Patterns

Burns with sharply defined edges or symmetrical patterns Immersion “glove” or “stocking”

patterns Pattern burns suggest stove

burners or heating grates Round symmetrical burns Cigarettes Car lighter

Abusive Burns

Scalding via hot water immersion, most commonly reported mechanism Abusive burns more severe and

complicated Typically < 6 yrs, on average 2 to 4 yrs Youngest child in family at greatest risk Abusive burn victims more likely to have

signs abuse/neglect and/or CPS reports 14 – 19% children with suspicious burns

have + skeletal survey

Patterns of Abusive Burns

Scald • Uniformity of burn depth – restrained • Bilateral symmetry without splash

marks - immersion Dry contact

• Silhouette of object Cigarette or cigar

• Circular pattern

Abusive Immersion Burns

Spare flexor creases – restrained or withdraw reflex

Spare soles of feet or point of contact with cooler surface

Linear or clear demarcation between burned and unburned (glove and stocking)

Uniformity of burn depth

Absence of splash

Hands, feet, genitalia, buttocks

Immersion Burns

Accidental Scald Burn

Splash marks Hot water splash >140F results in burn Burn less intense as liquid runs down

and dissipates heat Flexor creases spared due to withdraw

reflex Distribution and margins are asymmetric Pattern influenced by clothing and type

liquid

Thermal Contact Burns

Accidental Contact Burns

Indistinct margins Do not occur in multiples Usually on parts of body not

clothed (hands, feet, face)

Immersion burns

Why admit the child?

Over 25% of abused children have a previous, “minor” abusive injury 80% of “minor” injuries are bruises 66% occur prior to 3 months of age (Sheets 2013)

An abused child returned to an unsafe home is at

50% risk for additional injury and 10% risk of death (Green and Haggerty 1983)

Bruises in an immobile infant are nearly always due to abuse (Sugar 1999)

Incidence of Abusive Head Trauma peaks around 9-12 weeks of age

“Those who don’t cruise rarely bruise” Sugar NF, Taylor JA, Feldman KW. Bruises in infants and toddlers.

Arch Pediatr Adolesc Med. 1999:153:399-403.

• Neglect terms are accompanied by definitions

• Ages for injuries are based on epidemiology of abuse

• A pre-written policy reduces the influence of your emotions/relationships

• All cases meeting the above criteria require SW/CAP notification

Potential Screening Questions

Child Abuse: Management

Document Full P/E (rectal, genital) Photograph Labs: CBC, PT/PTT, LFTs,

lipase, U/A Skeletal survey CT head, abd prn Child Protection

Sometimes We Think Our Jobs Are Bad

Thank You!

Child Maltreatment 2013. Published: January 15, 2015. An office of the Administration for Children & Families, a division of U.S. Department of Health & Human Services. Retrieved from: http://www.acf.hhs.gov/sites/default/files/cb/cm2013.pdf U.S. Department of Health and Human Services, Administration for Children and Families, Administration on Children, Youth and Families, Children’s Bureau. (2013). Child Maltreatment 2012. Available from: http://www.acf.hhs.gov/programs/cb/research-data-technology/statistics-research/child-maltreatment United States Government Accountability Office, 2011. Child maltreatment: strengthening national data on child fatalities could aid in prevention (GAO-11-599). Retrieved from: http://www.gao.gov/new.items/d11599.pdf U.S. Department of Health and Human Services Administration for Children and Families Administration on Children, Youth and Families Children’s Bureau. Child Abuse and Neglect Fatalities 2011: Statistics and Interventions. Retrieved from: http://www.childwelfare.gov/pubs/factsheets/fatality.pdf Snyder, Howard, N. (2000, July). Sexual assault of young children as reported to law enforcement: victim, incident, and offender characteristics. Retrieved from: http://bjs.ojp.usdoj.gov/content/pub/pdf/saycrle.pdf

REFERENCES

Long – Term Consequences of Child Abuse and Neglect. Child Welfare Information Gateway. Washington, D.C.: U.S. Department of Health and Human Services, 2013. Retrieved from: http://www.childwelfare.gov/pubs/factsheets/long_term_consequences.cfm Fang, X., et al. The economic burden of child maltreatment in the United States and implications for prevention. Child Abuse & Neglect (2012) Retrieved from: http://www.sciencedirect.com/science/article/pii/S0145213411003140 Harlow, C. U.S. Department of Justice, Office of Justice Programs. (1999).Prior abuse reported by inmates and probationers (NCJ 172879) Retrieved from: http://bjs.ojp.usdoj.gov/content/pub/pdf/parip.pdf National Council on Child Abuse and Family Violence. Parental Substance Abuse A Major Factor In Child Abuse And Neglect. Retrieved from: http://www.nccafv.org/parentalsubstanceabuse.htm Swan, N. (1998). Exploring the role of child abuse on later drug abuse: Researchers face broad gaps in information. NIDA Notes, 13(2). Retrieved from the National Institute on Drug Abuse website: www.nida.nih.gov/NIDA_Notes/NNVol13N2/exploring.html

REFERENCES

Every Child Matters Education Fund. (2012). We can do better: Child abuse deaths in America (3rd ed.). Retrieved from: http://www.everychildmatters.org/storage/documents/pdf/reports/can_report_august2012_final.pdf Office on Child Abuse and Neglect, Children’s Bureau. Goldman, J., Salus, M. K., Wolcott, D., Kennedy, K. Y. (2003) A Coordinated Response to Child Abuse and Neglect: The Foundation for Practice, Chapter 5, retrieved from: https://www.childwelfare.gov/pubs/usermanuals/foundation/foundatione.cfm Wilson, E., Dolan, M., Smith, K., Casanueva, C., & Ringeisen, H. (2012). NSCAW Child Well-Being Spotlight: Adolescents with a History of Maltreatment Have Unique Service Needs That May Affect Their Transition to Adulthood. OPRE Report #2012-49, Washington, DC: Office of Planning, Research and Evaluation, Administration for Children and Families, U.S. Department of Health and Human Services. Retrieved from: http://www.acf.hhs.gov/sites/default/files/opre/youth_spotlight_v7.pdf Amy B. Silverman, Helen Z. Reinherz, Rose M. Giaconia, The long-term sequelae of child and adolescent abuse: A longitudinal community study, Child Abuse & Neglect, Volume 20, Issue 8, August 1996, Pages 709-723. Retrieved from: http://www.sciencedirect.com/science/article/pii/0145213496000592

REFERENCES